Monday, March 29, 2010

"Sexting" is a hot topic these days, especially in the wake of this month's U.S. Third Circuit Court of Appeals ruling in Miller v. Mitchell that it is unconstitutional to prosecute teens for child pornography solely based on their cell phone photos. The highly publicized Pennsylvania case illustrated the unintended consequences of current sex offender hysteria. The district attorney's office in Wyoming County had threatened to prosecute a teenage girl on felony child pornography charges unless she underwent mandatory reeducation. An appellate court barred the prosecutor from retaliating against young Ms. Doe for invoking her constitutional right not to attend the education program.

Sunday, March 28, 2010

Fear of complaints by disgruntled parents is deterring professionals from working in the child custody arena, creating a "major social and legal problem," according to a group of lawyers and forensic evaluators in Canada. The group is urging the Canadian government to change the law in order to restrict disciplinary complaints.

A plea signed by 11 psychologists, psychiatrists, lawyers and social workers “urges changing the rules so disciplinary bodies can only consider complaints from such parents if they have been first approved by the judge in the case or by the other, winning parent, or have been screened to weed out frivolous grievances,” according to an article in the National Post. As reporter Tom Blackwell explains it:

Experts are appointed jointly in custody cases to interview, observe and sometime conduct psychological testing on family members to help determine who is best able to care for the children of divorces. The work can take months and cost the parties up to $75,000.The lobby group is not looking to gain "immunity" for assessors from disciplinary charges, only to curb the high number of spurious complaints, said Nick Bala, a Queen's University law professor.

Saturday, March 27, 2010

Hearing voices lately? If not, that could be because corporate interests are using the legal system to keep critical voices from speaking out about controversial new tools in our field, according to European scholars.

A Swedish phonetics professor says when he challenged the premises underlying an Israeli voice risk analysis (VRA) lie detection system that the British government has spent 2.4 million pounds pilot testing, the manufacturer threatened his publisher into withdrawing a manuscript from press. The government wants to employ voice stress analysis to detect benefits fraud; here in the United States, police frequently use similar technologies in criminal interrogations.

Francisco Lacerda, the Stockholm University professor, said the censorship "showed how English law was damaging science abroad as well as in the UK," according to an article in the Times of London.

Responding to a series of similar high-profile defamation actions against scientists, a group called the Libel Reform Coalition is campaigning for changes in Britain's law. A Coalition petition, signed by about 44,000 people when I last checked, is online HERE; I encourage you to check out the group's website and sign the petition.

Thursday, March 25, 2010

When one introduces new chickens into an existing flock, the flock establishes a pecking order. The older birds peck the new ones into submission. With lower status, the new birds feel -- to anthropomorphise a bit -- inferior.

That's what happened when the upstart field of psychology pushed its way into the bastions of psychiatry. Psychiatrists bristled at the intrusion. Psychologists of necessity submitted to psychiatric authority. Now, years later, psychologists vastly outnumber higher paid psychiatrists in many mental health niches, but as a profession we still have an inferiority complex. Thus, we let a single psychiatric association in the United States dictate how mental functioning and impairment are conceptualized.

As the chorus of critical voices over the American Psychiatric Association's poorly drawn draft DSM-5 manual grows ever louder, some are urging psychology to issue a formal opposition paper. For example, Stephen Diamond, a clinical and forensic psychologist in Los Angeles, writes in Psychology Today that our profession's apathy "is a big part of the problem":

While clinical psychology has to some extent leaped onto this same biological bandwagon driven by contemporary psychiatry, seeking prescription privileges, some psychologists and other non-medical mental health professionals have practically written off the value and importance of psychodiagnosis today -- in part precisely due to its inherent medicalization, biological bias, dehumanizing labeling, and notorious inaccuracy…. [I]t is time for the leadership of the American Psychological Association to take a far more active and public role in the revision and direction of the DSM-5…. What, if anything, [is] the American Psychological Association is doing about DSM-V? Or about the hypermedicalization of psychology?

Allen Frances, the psychiatrist who chaired the DSM-IV task force, has become one of the most vocal critics of the manual's proposals. He too is calling on organized psychology to step up before it is too late. Taking his campaign directly to psychology and the general public, he hosts a "DSM5 in distress" column in the popular magazine Psychology Today that shines a spotlight by turn on various problematic aspects of the draft manual. In his recent call for an organized response from psychology, he writes that:

the American Psychiatric Association (APA) came to hold the DSM franchise only by historical accident…. Now that the DSMs have attained such importance, there have been repeated questions about the appropriateness of its continued sponsorship by more than just one professional organization…. The numerous problems that have bedeviled the development of DSM5 again raise the question whether the American Psychiatric Association should be sole steward of an official diagnostic system that impacts on all mental health disciplines…. Individual psychologists and the professional associations within psychology can play an important role in pointing the way forward for DSM5 and in protecting it from costly mistakes.

Perilous forensic consequences

Frances is increasingly focusing on the monumental potential for negative and unintended consequences in the forensic realm of the proposed changes:

The most obviously detrimental suggestions are in the paraphilia section, where the proposed change to the definition of paraphilia and the likely suggestion to introduce a new diagnosis of"paraphilic coercive rapism" will greatly compound the significant mischief already initiated by a seemingly trivial change in DSM-IV. More generally, even small changes in wording can result in large forensic confusion once parsed by lawyers in their peculiarly rigorous and tendentious fashion.The wording of every suggested option in DSM5 needs careful review by forensic experts.

"DSM-5 sexual disorders make no sense"

In a more recent column, Frances specifically targets the Big 3 sexual disorders that I have extensively blogged about. Of all of the DSM-5 work groups, he writes:

the Sexual Disorders Work Group has strayed furthest off the reservation. It has made a series of radical and dangerous suggestions that need to be dropped.... Each of the Work Group's suggestions is based on the thinnest of research support-usually a handful of studies often done by members of the committee making the suggestion. None has been subjected to, or could possibly survive, anything resembling a serious risk/benefit or forensic analysis.

As he points out, there are few researchers and little good research on sexuality. Consensus on the bounds of "normalcy" does not exist, and cultural bias plays a major role in what is defined as pathological (a point cogently made by Richard Green in his critique of the proposed hebephilia diagnosis). Especially important for my readers, "decisions regarding the diagnosis of sexual disorders can have profound and unanticipated forensic ... implications."

Regarding the three paraphilia proposals that will have the most impact in civil commitment proceedings in the United States, Frances had the following to say:

"Paraphilic Coercive Disorder"

This proposal was explicitly rejected for DSM IIIR and was given no serious consideration for DSM IV. The problem is the impossibility of reliably distinguishing between the small group of hypothesized "paraphilic" rapists (who would be given a mental disorder diagnosis) and the much larger group of rapists who are simple criminals.

The distinction has taken on huge significance because [of] SVP statutes mandating indefinite (usually in practice lifelong) inpatient civil psychiatric commitment for individuals who have (1) completed their prison sentence for a sexually violent crime, (2) have a diagnosed mental disorder, and (3) are deemed likely to repeat.... Although the SVP statutes have twice passed Supreme Court tests, they rest on questionable constitutional grounds and may sometimes result in a misuse of psychiatry.

Most disturbingly, an ad hoc and idiosyncratic suggested diagnosis -- Paraphilia Not Otherwise Specified -- has become a frequent justification for the psychiatric commitment of rapists who are really no more than simple criminals. Raising this diagnosis to official status would greatly compound this misuse of civil psychiatric commitment.

"Hypersexuality Disorder"

This is the strangest of constructs.... The fundamental problem with "hypersexuality" is that it represents a half baked, poorly conceptualized medicalization of the expected variability in sexual behavior.... The authors are trying to provide a diagnosis for the small group whose sexual behaviors are compulsive -- but their label would quickly expand to provide a psychiatric excuse for the very large group whose misbehaviors are pleasure driven, recreational, and impulsive. The offloading of personal responsibility in this way has already captured the public and media fancy and would spread like wildfire. Making an official mental disorder category of "hypersexuality" would also have serious unintended forensic consequences inthe evaluations of sexually violent predators (SVP).

"Pedohebephilia"

This new category would extend the traditional definition of Pedophilia ... to include pubescent teenagers. Clearly, sex with underage teenagers is reprehensible and deserves appropriate punishment under the penal code. It is, however, anything but clear when (and if) sexual behaviors with teenagers should qualify as a mental disorder. This diagnosis would be subject to the same misuses in SVP cases as has been described above.

With such widespread and vigorous opposition, it's hard to imagine these nutty proposals slipping into the DSM-5. But, stranger things have happened in the field of psychiatry.

Related article:DSM-5 and "Psychosis Risk Syndrome": Not Ready For Prime TimeDr. Frances' latest piece, in Psychiatric Times, is on Psychosis Risk Syndrome, one of the scariest diagnostic proposals. If adopted, it would likely lead to a wave of false-positive errors in which teenagers are wrongly identified as future schizophrenics and placed on dangerous antipsychotic medications.

This crisply written manual provides a balanced summary of the case law, empirical research, and developing practice standards for conducting insanity evaluations. Ira Packer, an award-winning scholar and long-time leader in the field of forensic psychology, brings a wealth of wisdom and experience to this topic. His discussions of controversial topics, such as whether to provide an “ultimate issue” opinion and how to approach the possibility of malingering, are especially balanced and nuanced.

Criminal responsibility evaluations are difficult endeavors both because of their retrospective nature, and also because we can never know for sure what was going on in someone else’s head, especially when that person may have understandable reasons to distort....

My full review is HERE. (Please be sure to click on "yes" if you find the review helpful; that boosts my Amazon ranking.)

Sunday, March 21, 2010

Your answer likely depends on whether you are a mental health professional, a layperson, or a member of the legal profession, where the term can have a highly scripted meaning with weighty implications.

In fact, the Supreme Court of Washington just ruled that the precise definition is so critical that a judge's refusal of a defense request to define it for a jury invalidated a civil detention order. That's because in Washington, a convicted sex offender cannot be civilly committed to a state hospital unless he has either a personality disorder or a "mental abnormality" that makes him more likely than not to commit sexually predatory acts in the future. The legal distinction between these two conditions derives from the DSM's axial system, under which most illnesses are listed on Axis I but personality disorders are categorized as "Axis II," because they are conceptualized (not always accurately) as more chronic and enduring than acute Axis I disorders.

At the trial of Curtis Pouncy, the prosecution-retained psychologist, Richard Packard, had testified that Curtis Pouncy had both conditions. The jury ultimately found Pouncy to be a Sexually Violent Predator (SVP), but it did not state whether this finding was on the basis of a personality disorder, a mental abnormality, or both. Explained the Supreme Court in overturning the commitment:

"The phrase 'personality disorder' is not one in common usage and is beyond the experience of the average juror. It is a term of art under the DSM that requires definition to ensure jurors are not 'forced to find a common denominator among each member's individual understanding' of the term…. We have no way of knowing from the verdict whether the jury found that Pouncy was an SVP because he suffered from a mental abnormality or a personality disorder. And, if the jury agreed Pouncy suffered from a personality disorder, we have no way of knowing what definition the jury used in reaching this conclusion…. We cannot say the failure to instruct on the definition of 'personality disorder' in no way affected the final outcome of the case; accordingly, it was not harmless. A new trial is required."

The government of Washington is so interested in the precise meaning of the term that in 2009 it actually codified the definition for purposes of SVP civil commitment. Tagging off of the definition in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the Revised Code of Washington Section 71.09.020(9) now defines a personality disorder as:

"an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has onset in adolescence or early adulthood, is stable over time and leads to distress or impairment. Purported evidence of a personality disorder must be supported by testimony of a licensed forensic psychologist or psychiatrist."

As Constance Holden reports in the current edition of Science magazine, "Personality disorders are hard to pin down. They don't have a common defining mood or behavior, people don't get hospitalized for having one, and a drug won't cure one."

If that sounds tricky, wait until the American Psychiatric Association adds layer upon layer of new complexity, and in the process completely scraps the definition as reified by government entities such as the Washington state legislature. Under a draft proposal rolled out last month for the new DSM-5* (due out in 2013), the old personality disorders are barely recognizable and some have disappeared altogether.

First off, the overarching definition will be new. Now, personality disorders are defined more briefly as:

"the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual's cultural norms and expectations."

Both self-identity and interpersonal functioning are then further defined. For example, poor interpersonal functioning involves failure to develop empathy, intimacy, cooperativeness, or "complexity and integration of representations of others."

Next, one rates the person on a set of six traits (negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy) to determine whether the general adaptive failure is "associated with extreme levels of one or more" of these.

Finally, there are the specific personality "types," whittled down from the current 10 to only five: Schizotypal, Borderline, Obsessive-Compulsive, Avoidant, and Antisocial/Psychopathic. Note that psychopathy will make its grand debut, while narcissistic exits stage left.

In his erudite competency opinion in the Brian David Mitchell case, Judge Dale Kimball leaned heavily on narcissistic personality disorder as an explanation for the defendant's presentation. If the Personality Disorders Work Group for the DSM-5 gets its way, that diagnosis will go the way of of hysteria and melancholia. Of course, as the judge wisely pointed out, DSM diagnoses are not directly applicable to ultimate legal issues:

"[I]t is not particularly necessary for the court to determine a specific diagnosis in determining competency.... [E]ither an Axis I or Axis II condition could potentially render a defendant incompetent. And, on the other hand, a defendant could have an Axis I and/or Axis II condition and still be competent."

So, what do you get when you combine five personality types with six crosscutting traits? "A camel -- a horse made by committee," psychologist Drew Westen of Emory University told Science magazine.

And in forensic contexts, how will terms such as "culturally adaptive," "empathy," "cooperativeness," "negative emotionality," and "antagonism" be operationalized? Based on research into how forensic evaluators decide about other value-laden constructs such as psychopathy and risk, dare I predict partisan allegiance will rear its ugly head?

Paul A. Siciliano at Basically Law has more on the Pouncy decision. Psychologist Simone Hoermann has commentary on the DSM-5 personality disorders revamp at her Personality Disorders blog.

*The current DSM and all previous editions are designated by Roman numerals, but the APA has decided to use Arabic numerals starting with the fifth edition.

Thursday, March 18, 2010

During one of my stints as a prison clinician, I had the unfortunate experience of being supervised by a psychologist who believed that prisoners were monsters bent on manipulation, and who thus tried to thwart my attempts to provide treatment. That psychologist's favorite book: Stanton Samenow's Inside the Criminal Mind.

"Criminals think differently" is the basic premise of the well-worn treatise. Samenow rejects out-of-hand most mainstream sociological, environmental, traumatogenic, developmental, biological, and psychological theories of crime, labeling them as absurd, simplistic, or even plain "kooky":

[C]riminals are not mentally ill or hapless victims of oppressive social conditions…. Despite a multitude of differences in their backgrounds and crime patterns, criminals are all alike in one way: how they think…. [A]ll regard the world as a chessboard over which they have total control, and they perceive people as pawns to be pushed around at will…. Some of their most altruistic acts have sinister motives.

Samenow promotes this popular rhetoric on national TV and radio shows such as Good Morning America and the Larry King show. In court, the well-known psychologist has testified for many decades in insanity cases, being called exclusively by the prosecution to attack defendants' claims of insanity. Over time, this one-sidedness started working to defense attorneys' advantage; they were able to rebut his testimony simply by telling juries that Samenow always testified against insanity. (Here is a recent example.)

This month, however, Samenow broke with tradition and for the first time opined in court that a defendant met the legal standard for insanity. He picked a rather unusual case. Unlike most defendants who plead insanity, Evan D. Gargiulo, being prosecuted in Virginia for the shooting death of a cab driver, had no history of psychiatric disorder. The competitive swimmer and former college swim team coach was an engineer for Lockheed Martin and a lieutenant in the National Guard when he shot Mazhar Nazir in the back of the head with his 9 mm pistol.

Gargiulo testified that he shot Nazir in self defense when the Pakistani-born cabbie tried to grab him. He said that after getting a taxi ride home from a nightclub, he realized he had lost his wallet. He went into his apartment, retrieved his gun and car keys, and had Nazir drive him to his car. Once there, he realized he had also lost a roll of cash so could not pay his $130 fare. It was at that point, he claimed, that Nazir became angry and reached over the seat to grab him, making him fear for his safety. The hapless driver died from a single gunshot to the back of his head.

Samenow testified that Gargiulo had led such a sheltered life, and had developed such an exaggerated paranoia, that he could not distinguish right from wrong at the time of the crime. As Tom Jackman of the Washington Post reported it:

Samenow said Gargiulo's dismay at being robbed and his "enormous fear" of Nazir caused him to shoot without thinking of the consequences. "I haven't encountered somebody with this level of fear," Samenow said. He said there is no formal definition of Gargiulo's mental condition in the Diagnostic and Statistical Manual of Mental Disorders, the accepted reference book for courts trying to parse mental illness and criminal culpability.

Samenow said later that his first appearance for the defense in an insanity case in 40 years showed that he has an open mind after decades of examining mentally ill defendants and finding them criminally responsible. He testified that he was paid $25,000 by the defense, which rested with Samenow as its only witness.

The jury didn't buy either the self defense or insanity defenses. After six hours of deliberations, it convicted Gargiulo of second-degree murder and sentenced him to 15 years in prison. To the disappointment of the victim's family, that was 25 years less than the maximum the jury could have imposed.

For you Californians, I’ve got some good news on the training that I am giving at the Forensic Mental Health Association conference March 24-26 in Seaside. The organizers have just doubled my time slot: I will now be presenting for the entire afternoon of Thursday, March 25. If you are free that day, there is still time to sign up. Registration information is online HERE.

My topic is Ethical Considerations in Psychiatric Diagnoses in Forensic and Correctional Settings. I will give an overview of ethics issues in the use of diagnostic labels in court and in correctional settings before focusing specifically on controversial diagnoses that are often invoked in adversarial legal contexts. Diagnoses of focus will include Antisocial Personality Disorder and the sexual paraphilias, including pedophilia and the novel diagnoses being proposed for the upcoming DSM-5 (e.g., "Paraphilic Coercive Disorder" and "Pedohebephilia").

Please note that the time listed in the program brochure for my training is incorrect. My new, expanded time slot is from 1:30 to 5:00 p.m.

This year's legal track, focusing on competency to stand trial in California (see my previous blog post), has also been expanded and will include some exciting new presenters.

All types of continuing education credits are being offered for professionals in the fields of mental health, law, and law enforcement.

Tuesday, March 16, 2010

Although the construct of hypersexuality is becoming popular with clinicians, strong empirical evidence for its validity is lacking, according to a new critique in the Archives of Sexual Behavior. The author, Jason Winters, is a research psychologist involved with the High Risk Sex Offender Program of the Forensic Psychiatric Services Commission in Vancouver, BC.

As with other disorders being proposed for DSM-5, due out in 2013, the boundary between normalcy and supposed pathology is fuzzy and arbitrary, writes Winters. Findings from a recent Internet survey he conducted suggest that more than four out of every ten men and one out of five women might meet the "excessive sexuality" criterion, operationalized as an average of seven or more orgasms per week.

And if behaviors that interfere with other responsibilities are evidence of pathology in the sexual realm, why not create formal mental disorders for other types of preoccupations? For example, why not pathologize a tenure-track professor who prioritizes academic work over family and friends? (I was glad Winters did not mention excessive blogging as an example of a potential mental illness, but then I remembered that Internet Addiction has already been proposed for the DSM.)

The criterion of engaging in sexual behavior to enhance mood is similarly problematic:

[I]f we are to accept that repeatedly engaging in sexual behaviors to enhance mood is symptomatic of a distinct sexual disorder, then we must also be willing to accept that repeatedly engaging in non-sexual rewarding behaviors for a similar effect is symptomatic of other corresponding mental disorders…. [But] the DSM does not include disorders of watching too much television, or shopping, exercising, or working too much.

As Winters points out, an unstated bias against sexual expression outside of a traditional monogamous marital dyad seems the basis for calling some sexual behaviors -- such as one-night stands, anonymous sex, and multiple partners -- evidence of disease.

Ultimately, he concludes that while excessive sexuality may be problematic and distressing for some, and in such cases merits clinical attention, a new diagnosis may be of "dubious value."

Except, I might add, to the civil commitment industry, increasingly desperate for new diagnoses to justify the civil commitment of sex offenders who do not qualify for recognized mental illnesses.

Sunday, March 14, 2010

In 1998, the Crowe family in Escondido, California awakened to their worst nightmare. Twelve-year-old Stephanie was lying in a pool of blood on her bedroom floor, dead from multiple stab wounds. Police quickly zeroed in on a suspect -- Stephanie's 14-year-old brother Michael. After a series of grueling interrogations, Michael ultimately admitted he may have killed his sister. He and two friends were arrested for murder.

Only through serendipity were the boys' charges dismissed more than a year later, when DNA evidence proved that a mentally ill transient had committed the murder. That man, Richard Tuite, was ultimately convicted of manslaughter.

Now, the Ninth U.S. Circuit Court of Appeals has reinstituted the families' civil rights case against the police, dismissed by a federal judge several years ago. Writing for the three-judge panel, Justice Sidney R. Thomas described the shocking nature of the interrogations:

One need only read the transcripts of the boys' interrogations, or watch the videotapes, to understand how thoroughly the defendants' conduct in this case "shocks the conscience." Michael and Aaron [Houser] -- 14 and 15 years old, respectively -- were isolated and subjected to hours and hours of interrogation during which they were cajoled, threatened, lied to, and relentlessly pressured by teams of police officers. "Psychological torture" is not an inapt description.

"Psychological torture" and "brutal and inhumane" were descriptions given by a juror in the real killer's criminal trial after he viewed the videotaped interrogations. (I show the heartwrenching video, which is no longer available commercially, in my forensic courses.) Dr. Richard Leo, an expert in coerced confessions and author of Police Interrogation and American Justice (read my review HERE), echoed the juror's sentiments, describing Michael's interrogation as "the most psychologically brutal interrogation and tortured confession that I have ever observed." So did Dr. Calvin Colarusso, Director of Child Psychiatry Residence Training Program at the University of California, San Diego, who evaluated Michael and described the interrogation as "the most extreme form of emotional child abuse that I have ever observed in my nearly 40 years of observing and working with children and adolescents."

The appellate victory will allow the families' federal civil rights case to move forward to a jury trial or a settlement. In an interesting angle, the justices also reinstated the claim against a psychologist whom police consulted during the interrogation. The plaintiffs allege that Dr. Lawrence "Deadlift" Blum, a police psychologist, conspired with Escondido police, helping them formulate a "tactical plan" that they followed in their interrogation. Blum admitted in a deposition that he told a police detective that 15-year-old Aaron Houser, Michael's friend, was a "Charlie Manson wannabe."

The ruling coincides with publication of a landmark article sponsored by the American Psychology-Law Society (AP-LS) on the scientific status of coerced interrogations and false confessions. The article, written by leading scholars Saul M. Kassin, Steven A. Drizin, Thomas Grisso, Gisli H. Gudjonsson, Richard A. Leo, and Allison D. Redlich and published in this month's Law & Human Behavior after an extensive process of vetting and review, is only the second such paper authorized by AP-LS in its 42-year history. The first was a 1998 white paper on eyewitness identification. As William C. Thompson, criminology and law professor at the University of California at Irvine, notes in the introduction to the special issue:

That paper (Wells, Small, Penrod, Malpass, Fulero, & Brimacombe, 1998) proved extremely influential in subsequent policy debates about line-ups and other eyewitness identification procedures. By providing an intellectual framework for analysis of systemic factors that affect eyewitness accuracy, and by distilling specific policy recommendations from a broad array of research, it set the agenda for policy discussion and channeled those discussions in productive directions. The paper was the foundation for a subsequent National Institute of Justice policy paper. Many of its recommendations, such as procedures for composing line-ups and instructing witnesses, are beginning to be implemented nationwide.

The AP-LS hopes the current review article will have a similar effect on the field. After methodically reviewing the state of the science, the authors make a number of critical recommendations for reform aimed at reducing the number of false and/or coerced confessions. These include:

Mandatory electronic recording of interrogations, with the camera angle focused equally on the suspects and detectives

Limits on the duration of interrogations

Limits on the presentation of false information and evidence

Special protections for vulnerable suspects, including juveniles and those with cognitive and/or psychiatric impairments

Michael Crowe's exoneration came about as a result of what author Edwin Borchard described in a 1932 tome on wrongful convictions as "sheer good luck." The scholars who collaborated on this white paper hope that their recommendations will reduce the role of such serendipity, by giving police, prosecutors, judges, and juries the scientific information necessary to reduce egregious injustices like the one in Escondido 12 years ago.

Friday, March 12, 2010

In the wake of last week's competency finding, a date of Nov. 1 has been set for Brian David Mitchell's federal trial in the kidnap-rape of Elizabeth Smart of Utah. The defense has indicated it plans to mount an insanity defense. As reported by the Associated Press today, a parallel case in state courts has stalled over the question of Mitchell's competency.

I'm still wading through Judge Kimball's 149-page ruling on competency, which I highly recommended to any of you who do competency work. In describing Mitchell as a cunning malingerer, the decision has plenty of implications for the insanity trial as well.

The parody of science masquerading as democracy made a laughing stock of psychiatry and the APA when it held a popular vote by its membership on whether homosexuality should remain a mental disorder. Decreeing in a few years time that 19-year-olds who prefer sex with 14-year-olds (5 years their junior) have a mental disorder … will not enhance psychiatry’s scientific credibility.

As he points out, the age of legal consent in several European countries falls within the range that the proposed pedohebephilia disorder would make pathological for the older participant:

If the general culture is accepting of participation by the younger party, but psychiatry pathologizes participation by the older party, then the mental health profession pronounces a moralistic standard and, if successful, becomes an agent of social control.

Green goes on to catalog "biased terms" and "logically frail arguments" in the proposal. In this, he joins a growing chorus of voices sounding the alarm about myriad problems with the proposed pedohebephilia diagnosis.

Coming at it from the opposite angle of most critics is William O'Donohue, a psychology professor at the University of Nevada at Reno and co-editor of the second edition of the widely consulted text Sexual Deviance.

O'Donohue argues for keeping it simple: "any sexual attraction to children … is a pathological, abnormal condition." His proposed diagnosis reads as follows: "The person is sexually attracted to children or adolescents under the age of 16" as evidenced by (1) self report, (2) laboratory findings, and/or (3) past behavior. Whether the person has acted on his or her attractions would not matter. The number of victims would not matter. And internal distress would not be required.

O'Donohue expresses a lack of concern over the inevitable false positive errors that such a broad net would ensnare. He argues that we should be more concerned about false negative errors -- pedophiles who escape diagnosis when the criteria are too narrow, for example when more than one known victim is required. And he applauds the move to expand pedophilia to include hebephilia, or attraction to pubescent minors.

Prosecution-retained evaluators in U.S. civil commitment cases will be salivating at the prospects for this one. But consider the source. O'Donohue is the psychologist who has argued for subjecting gay and lesbian parents to special scrutiny in child custody evaluations. (Respected child custody experts Jonathan Gould, David Martindale, and Melisse Eidman wrote an outstanding counterpoint, summarizing the empirical research as indicating that "sexual orientation is not a pertinent factor when considering the best psychological interests of children." In the interest of full disclosure, I share that view, as I wrote in an article published in the same journal a few years earlier.)

And, despite his support for diagnostic expansion, even O'Donohue concedes that the psychometric properties of the proposed diagnosis remain unknown. In other words, neither its reliability nor its validity have been empirically established. A wee problem, that.

A list of published articles on the hebephilia debate, with links to the publisher's web pages, is HERE. For the newest additions, look for the "NEW" icon towards the bottom of the page.

Thursday, March 11, 2010

You evaluate a man who engaged in repetitive stalking of a high school girl. He spied on her, followed her around (rationalizing it as “for her own good”), and even climbed in her bedroom window at night and watched her sleep. He acknowledges a powerful desire to kill her.

Ominous, right? When we encounter men like this, they raise our hackles.

But in pop culture -- movies, music, and videos -- this possessive, condescending, and downright creepy behavior is often glorified as "true love." Such is the case with Edward in the blockbuster Twilight movie series, marketed with great fanfare to young teenage girls.

Appalled by the sexually predatory behavior modeled by Edward in Twilight, freelance Web designer Jonathan McIntosh of Rebellious Pixels asked himself, "What would Buffy do?" Buffy, of course, being the strong woman heroine of the popular TV series Buffy the Vampire Slayer.

If you haven’t seen the resultant video mashup, stop whatever you're doing and take the six minutes to watch it.

The brilliant and hilarious video has been translated into 16 languages and watched by millions of people worldwide. As reported in the L.A. Times, Buffy v. Edward reveals Edward’s supposed charm for the creepy stalker behavior it is:

[T]he Slayer has little patience for the expertly coifed Edward, dazzling or otherwise. "Being stalked isn’t a big turn-on for girls," Buffy tells him. When Edward tries to explain that he's on "a special diet," Buffy replies, "What are you doing? Here, at this table, talking to me like we're some kind of talking buddies?"

Friday, March 5, 2010

In a new prospective study out of Austria, none of the actuarial instruments commonly used to predict sex offender recidivism were able to predict sexually violent recidivism among a group of sex offenders released from prison after treatment.

The interesting study, just published in the International Journal of Offender Therapy and Comparative Criminology, was designed to validate German versions of commonly used actuarial tools, including the Static-99, RRASOR, SORAG, and SVR-20. It followed about 400 Austrian prisoners for an average of three years in the community.

The main problem obtaining significant results was that recidivism was so rare. Obviously, the less likely an event is to occur, the harder it is to accurately predict. Only seven offenders in the entire sample committed a new hands-on offense during the followup period, and most of those were extrafamilial child molesters. Recidivism base rates were especially low for rapists and incest offenders.

The results echoed findings in two other recent studies in which the actuarials failed to demonstrate good predictive validity for predicting sexually violent reoffending.

Most of the instruments did better when recidivism was defined more broadly, to include all sexual reconviction, even hands-off offenses such as voyeurism or exhibitionism that is not typically defined as sexually violent under civil commitment laws. Even including these lesser offenses, the overall base rate for all sexual recidivism among this sample was still quite low, 4.3% (12% among extrafamilial child molesters, 1.7% among rapists, and about 1% among incest offenders).

When extrafamilial child molesters -- the group most likely to reoffend -- were examined separately, all of the instruments except the RRASOR had some predictive utility, with the SVR-20 doing the best. Still, neither the Static-99 (the most widely used actuarial tool) nor the RRASOR could significantly predict sexually violent reoffenses even for that relatively higher-risk group.

"From the results of these studies and of the present study, the actuarial prediction of some reoffence categories in at least some offender subtypes is less accurate than generally assumed,” the authors concluded. "One major aim of most criminal justice systems is to calculate risk by predicting the probability of severe sexual crimes. This goal obviously is not yet achieved satisfactorily by actuarial risk assessment, because results are far from ideal, especially when time-at-risk periods are relatively short."

An important implication of this study is that evaluators need to consider offender subgroups separately, rather than lumping all types of sex offenders together. Recidivism varies tremendously by type of offender (e.g., rapists versus child molesters) and by how recidivism is defined, with the various instruments doing better at some types of predictions than others. Furthermore, so little outcome research exists on certain groups (such as hands-off offenders, juveniles, the intellectually disabled, and offenders with only adult male victims) that the actuarials may be inappropriate to use at all.

FURTHER READING: For those of you interested in the actuarials, I also recommend "More prejudicial than probative?," a stastical critique by David J. Cooke, a forensic psychology professor in Glasgow who is an expert scholar and trainer on violence risk assessment. Cooke argues that the actuarials are compelling because they are simple to use by paraprofessionals and have a scientific veneer, but "the scientific basis for actuarial scales, as applied to individuals, may be more illusory than real." The article, in the journal of the Law Society of Scotland, is available online. It also includes useful references to other sources.

Wednesday, March 3, 2010

A French anti-smoking campaign comparing smoking to sex slavery is being accused of everything from dissemination of pornography to insensitivity to child sexual abuse victims.

The ads -- set to be published in newspapers and posted in bars -- feature teens smoking cigarettes in such a way that they look like they might be performing oral sex on a man in a suit. The caption reads, "Smoking means being a slave to tobacco."

"Traditional advertisements targeting teens don't affect them. Talking about issues of health, illness or even death, they don't get it," a spokesperson for the Association for Nonsmokers' Rights told AP in explanation. "However, when we talk about submission and dependence, they listen."

The 16-year-old who alerted me to the controversy thought it was quite a hoot. But the family minister of France is not laughing. She is calling for a ban on the ads as "indecent exposure" and "an affront on public decency." Likewise, a child welfare group called the ads cruel and insensitive toward young child abuse victims. Tobacco company representatives are also incensed at being compared to pedophiles. "It's no longer prevention, but out of place provocation," one tobacco association said on its web site.

Ironically, the advance uproar is giving the anti-smoking campaign so much publicity that it will make the formal ad campaign unnecessary.

The program was launched in 1999 and has so far cost an estimated 200 million pounds (more than $300 million USD), with little evidence of efficacy in identifying dangerous criminals or curbing violent crime. The four DSPD units -- two at Broadmoor and Rampton high security hospitals and two at Whitemoor and Frankland prisons -- house about 300 offenders. Critics say the label Dangerous and Severe Personality Disorder is a political invention, not a true psychiatric disorder.

According to an exclusive report by London's independent Channel 4 News, the Ministry of Justice is considering a halt to the program based in part on a report that concludes that the program "has been largely ineffective and should now be abandoned." The report, co-authored by former government advisor Peter Tyrer, is under review for the journal Medicine, Science and The Law, published by the British Academy of Forensic Sciences.

Ullrich and colleagues found that 26 DSPD offenders would need to be civilly committed to prevent one major violent act. In regard to sex crimes, the researchers found that most were committed by offenders who were NOT categorized as DSPD, undermining the UK Home Office and Department of Health assumption that offenders at the highest risk for future sex offending would be categorized as DSPD.

If Britain does indeed eliminate the DSPD program, it will be a major blow for those who advocate for civil commitment as a viable means of increasing public safety. Not only is it exorbitantly expensive, but also the civil liberties implications of wrongfully detaining people who are not truly dangerous based on unreliable prediction tools are ominous.

It will also be a blow against the creation of dubious new diagnoses to justify civil commitment on the grounds of purported mental disorder, as is being done here in the United States.

Finally, this scientific setback may also help to discourage those who seek to extend civil commitment to other populations, such as juveniles.

Monday, March 1, 2010

With the unveiling of the draft DSM5, the chorus of well-aimed criticisms flying in from all sides is becoming truly spectacular. The latest voices are prominent scholars writing in the eminently respectable Wall Street Journal, Los Angeles Times, and Washington Post.

All three focus on what most critics agree is an especially troubling aspect of the proposed manual -- the "wholesale medical imperialization" that eventually will label nearly every human being with one or more psychiatric pathologies. The authors of the DSM, critics assert, have appointed themselves as the arbiters of what is normal and what is not.

Edward Shorter, a University of Toronto professor and preeminent scholar of the history of medicine, gives a historical overview of the DSM's development to support his verdict that the latest draft manual illustrates a discipline in demise.

To flip through the latest draft of the American Psychiatric Association's Diagnostic and Statistical Manual, in the works for seven years now, is to see the discipline's floundering writ large. Psychiatry seems to have lost its way in a forest of poorly verified diagnoses and ineffectual medications. Patients who seek psychiatric help today for mood disorders stand a good chance of being diagnosed with a disease that doesn't exist and treated with a medication little more effective than a placebo.

Allen Frances, chairman of the DSM-IV task force, has been sounding the alarm over this new manual far and wide of late. This latest essay is perhaps his most eloquent to date, and of direct relevance to forensic practice in that it focuses on the proposed sexual disorders that will be used pretextually in civil commitment proceedings:

The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day -- despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.

The sexual disorders section is particularly adventurous. "Hypersexuality disorder" would bring great comfort to philanderers wishing to hide the motivation for their exploits behind a psychiatric excuse. "Paraphilic coercive disorder" introduces the novel and dangerous idea that rapists merit a diagnosis of mental disorder if they get special sexual excitement from raping….

Frances urges the public to pay attention and voice opposition to psychiatry's "recklessly expansive suggestions" before the juggernaut becomes unstoppable:

This is a societal issue that transcends psychiatry. It is not too late to save normality from DSM-V if the greater public interest is factored into the necessary risk/benefit analyses.

Finally, prominent political columnist George F. Will weighed in on the moral implications of the proposed diagnostic expansions. Will expressed worries about the legal consequences of excusing amoral conduct as a symptom of uncontrollable illness.

The 16 years since the last revision evidently were prolific in producing new afflictions. The revision may aggravate the confusion of moral categories.

[C]onfusion can flow from the notion that normality is always obvious and normative, meaning preferable. And the notion that deviations from it should be considered "disorders" to be "cured" rather than stigmatized as offenses against valid moral norms.

Now that just about every major news outlet in the United States has run highly critical analyses, the question becomes: Will the American Psychiatric Association listen? Or, like an individual in the throes of a manic episode, will it continue its pell-mell rush to diagnose all human behaviors, creating an ever-broader assortment of bizarre pathologies?

Checking for updates on the Elizabeth Smart case for tonight's lecture on competency restoration, I see that the judge ruled just moments ago that Brian David Mitchell is competent to stand trial.

In an opinion that went on for a hefty 149 pages, U.S. District Judge Dale Kimball agreed with prosecution psychiatrist Michael Welner that Mitchell is a psychopath who is faking mental illness to avoid criminal responsibility. The 56-year-old alleged kidnapper "does not presently suffer from a mental disease or defect that impedes his rational and factual understanding" of the proceedings against him, the judge ruled.

The decision came after a 10-day competency hearing at which Dr. Jennifer Skeem testified that Mitchell suffered from a delusional disorder and was incompetent.

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Karen Franklin, Ph.D. is a forensic psychologist and adjunct professor at Alliant University in Northern California. She is a former criminal investigator and legal affairs reporter. This blog features news and commentary pertaining to forensic psychology, criminology, and psychology-law. If you find it useful, you may subscribe to the newsletter (above). See Dr. Franklin's website for more information.

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